Risk Factors


Pre-existing respiratory conditions (asthma, pneumonia)
A previous anaphylactic reaction or pre-existing
allergies
Signs & Symptoms
Neurological: headache, dizziness, paresthesia, feeling of
impeding doom
Skin: pruritis, angioedema, erythema, urticaria
Respiratory: hoarseness, coughing, sensation of narrowed airway,
wheezing, stridor, dyspnea, tachypnea, respiratory arrest
Cardiovascular: hypotension, dysrhythmias, tachycardia, cardiac
arrest
Gastro-intestinal: abdominal pain, cramps, nausea, vomiting,
diarrhea
Etiology




Respiratory failure from severe bronchospasm or laryngeal
edema which may lead to brain damage
Myocardial infarction
Kidney failure
Death
Diagnosis
Anaphylaxis
Medical Management (Pharmacological/Surgical)
Epinephrine

Used in cases of anaphylaxis to produce bronchodilation

Adverse effects: tremors, anxiety, headache, dizziness,
palpitations, tachycardia, HTN, N&V. dyspnea
o Assess lung sounds and monitor vitals especially BP and HR
continuously
o Paradoxical bronchospasms may occur and if they do
medication should be stopped immediately
Diphenhydramine

Used to relieve allergy symptoms by competing with
histamine for receptors and blocking histamine

Adverse effects: dizziness, drowsiness, hypotension, urinary
retention, thrombocytopenia, increased thick secretion
o Assess respiratory rate and cough and provide fluids to
decrease secretion thickness
o Monitor I&O ratio and CBC
o Caution patient to avoid hazardous activities due to
drowsiness
Methylprednisolone

Decreases inflammation

Adverse effects: flushing, sweating, HTN, embolism,
tachycardia, diarrhea, pancreatitis
o Monitor weight, monitory for infection
o Caution patient to not discontinue abruptly
o Teach patient signs of adrenal insufficiency: nausea,
anorexia, fatigue, dizziness, dyspnea, weakness, joint pain
Albuterol nebulizer

Increases ability to breath by causing bronchodilation

Adverse effects: tremors, headache, palpations, tachycardia,
flushing, dry throat
o Assess respiratory function
o Advise patient to limit caffeine products
Potential Complications
Anaphylaxis is the most severe, life-threatening
hypersensitivity reaction and it can occur when a patient
is in contact with a foreign object. Medication is the most
common cause of anaphylaxis. Other common causes
include foods (milk, eggs, nuts), animal serums (snake
venom, rabies), insect stings, and latex.
Labs/Diagnostic Tests





CBC with WBC differential (including absolute lymphocyte
count and eosinophil count
Total serum immunoglobulin E levels
Plasma histamine
Allergy skin test/blood test
Cardiac monitoring
Nursing Management/Care
Nursing Diagnosis

Assessment Findings
Objective data:

Vitals: BP, O2, HR, T, RR

Chest X-rays

Lab tests

Respiratory assessment

Physical assessment

Comprehensive health/allergy
history

Diaphoresis

Edema

Redness

Urticaria

Laboured breathing

Patient is panicked
Subjective data:

27 year old male

Pain

Complain of coughing, chest
tightness or difficulty breathing

“I feel like my throat is swelling up”

Abdominal cramping
Health Teaching



Teach patient
about the
medication that
caused
anaphylaxis
Teach patient and
family how to use
auto-injector
epinephrine in
case of future
exposure
Teach patient and
family about the
signs and
symptoms of
anaphylactic
reaction


Ineffective airway clearing related to bronchospasms and
laryngeal edema
o Position patient in semi recumbent position with head
of the bead at 30-to-45-degree angle
o Monitor respiratory pattern including rate, depth, and
effort as well as other vitals
o Administer oxygen as ordered
o Administer medication such as bronchodilators or
inhaled steroids as ordered
Impaired skin integrity related to improper circulation
o Assess edema
o Assess skin for pruritus as itching can result in
disruption of skin integrity
o Implement treatment plan for topical treatment of the
site of skin impairment
o Obtain precise history of allergies as well as medication
and foods taken
Anxiety related to threat of current status
o Offer the client accurate information to help reduce
irrational thoughts and fears
o Recognize awareness of patient’s anxiety
o Encourage controlled breathing
o Teach client healthy anxiety managing techniques
References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to
planning care. St. Louis, MO: Elsevier.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarths textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer
Lewis, S. L., Bucher, L., MacLean Heitkemper, M., Harding, M. M., Barry, M., Lok, J., Tyerman, J., & Goldsworthy, S. (Eds.). (2019). MedicalSurgical Nursing in Canada: Assessment and Management of Clinical Problems (4th ed.). Elsevier Canada
Skidmore-Roth, L. (2015). Mosbys Drug Guide for Nursing Students. Mosby.